Patient, Provider Concerns Simplify TRICARE

The TRICARE Management Activity began implementing changes in February that will make it easier, and cheaper in many cases, for Military Health System beneficiaries to get health care. Many of the changes also will make TRICARE participation more attractive to physicians, according to a senior health policy analyst here.

"What these changes have done is eliminate a lot of the fine print in TRICARE coverage," said Air Force Lt. Col. Kathy Larkin. "We have been very committed to protecting our beneficiaries and eliminating confusion for our providers."

Larkin described some of the changes, explaining how the system worked before and after the changes were made or will work after the changes are implemented. These improvements include:

Balance Billing for Specialty Care

One of these changes affects how much enrollees in TRICARE Prime, the military health system's managed care option (standard for active duty service members), must pay for authorized care from a civilian specialist who is not in the TRICARE network. Until things changed in March, patients were responsible for any costs over the "balance billing limit" of 115 percent of the CHAMPUS "maximum allowable charge" -- the most that old plan would have paid participating providers for a specific service.

"When TRICARE Prime enrollees follow the rules by getting authorization for specialty care, they will only pay their co- pay rate," Larkin said. "If the specialist isn't in the TRICARE network and charges more, the managed care support contractor for that region will pay the difference." Co-pays are $6 for family members of active duty service members E-4 and below; and $12 for family members of active duty service members E-5 and above and retirees and their family members.

Balance Billing Limits for Nonprofessional Services

A second change applies limits to balance billing for ambulance companies and clinical laboratories and other noninstitutional, nonprofessional providers.

"An ambulance company can charge anything it wants," Larkin said. The new balance billing provision protects Prime enrollees, but TRICARE Standard users could get stuck with a big bill. "If we said the ambulance ride was worth $100 and the company charged $1,000, legally that beneficiary was responsible for the $900 difference," she said. "Now, we've applied a 115 percent limit." So in her example above, TRICARE would pay the $100 minus the beneficiary's cost share, and the beneficiary would pay the remaining $15.

Increased Maximum Allowable Charges

TRICARE identified 62 medical procedures for which the CHAMPUS Maximum Allowable Charge was lower than the Medicare fee schedule amount. This was a disincentive for civilian physicians, Larkin said. TRICARE increased the maximum allowable charges to match Medicare fees for all 62 procedures Feb. 1.

Single Payment for Ancillary Services

Before March, civilian medical professionals' bills often included multiple additional charges for blood work, throat cultures, X-rays and other lab services. Often, each of the different labs would bill separately and expect to apply the beneficiary's co-payment to its bill.

"The co-payment might be applied two or three times, even if the beneficiary didn't even go anywhere but the doctor's office," Larkin said. TRICARE eliminated co-payments for these ancillary services, so there's no question about whether a co-payment should be applied.

Automatic Renewal of Prime Enrollment

Enrollment in TRICARE Prime is for 12 months. In the past, enrollees had to fill out forms to continue in the Prime program. Otherwise, TRICARE assumed they wanted out and the enrollment would expire after the 12th month.

"You had to do something to stay enrolled," Larkin said. "Now, you will be automatically continued unless you do something." This applies primarily to active duty family members, who aren't charged enrollment fees. Retirees have to pay for their renewal. However, TRICARE plans to implement a monthly payment schedule for retirees, with electronic funds transfers or retiree allotments. "That would just click right along" until retired beneficiaries voluntarily disenroll, Larkin said.

Claims Appeal Process for Providers

TRICARE requires contractors to use ClaimCheck software to detect incorrect billing by providers. Some providers didn't like the software and wanted TRICARE to develop a review process. Congress required TRICARE to establish an appeals mechanism.

"We've put a notice in the Federal Register, notifying the public that we do, in fact, have a review and appeal mechanism currently in place and that we're working toward streamlining that," Larkin said. "I think this demonstrates that we listen to provider concerns and try to address them."

Alternative Optometry Benefits

TRICARE wants to streamline the optometry benefit. Active duty family members currently get an annual eye exam benefit in TRICARE Standard and Extra, and periodic exams in Prime. Retirees in Prime also get the periodic benefit but receive no optometry benefits under Standard or Extra.

"We need to simplify the benefit, and we're working on how best to do that," Larkin said.

Medical Necessity Review for Outpatient Procedures

TRICARE decides whether 17 different outpatient procedures are necessary before it authorizes beneficiaries to have them done - - even when they have other health insurance that pays before TRICARE.

When people used TRICARE as a second payer, the medical office manager had to obtain separate reviews and authorizations from both the primary insurer and TRICARE, Larkin said.

"While we still want to pay for medically necessary care, we can look at it retrospectively," she said. "We just want to make our program easier to use, and less complicated for the civilians out there who are trying to work with us."

A number of other changes have already simplified TRICARE programs, Larkin said. TRICARE now is available worldwide, and Prime enrollees can transfer their enrollments when they move to a new region. The claims process has been simplified, a major incentive for civilian practitioners to join TRICARE networks. And, she noted, the National Mail Order Pharmacy makes it easier for beneficiaries worldwide to get their prescriptions filled.

Army Col. Karen Ferguson said the change spreadsheet has become a sort of virtual document within the TRICARE Management Activity. Inclusion on the sheet underscores the importance of an initiative or problem, she said.

As director of program development, Ferguson is in on any new ideas put forth. She said the concerns come from a variety of sources, from patients to providers -- and because most of the TRICARE staff is military, they have a strong interest in ensuring the program works better for everyone.

"We're all retirees in training," Ferguson said.

"We want to make TRICARE the world's leading integrated health system," Larkin said. "We want to be good stewards of the government's money, but the care of our beneficiaries is our highest priority."